Assessment Criteria

1. Quality of Care

  • Documented investigation appropriate to patient's complaint/condition
  • Appropriate diagnoses are reached
  • Management plan and medication prescribed are appropriate to condition being treated
  • Indications for surgical and other procedures are documented and appropriate
  • Adequacy of treatment of both acute and chronic conditions
  • Counselling and psychotherapeutic sessions are appropriately indicated
  • Utilization of support and community resources
  • Practice guidelines are being followed
  • Evidence of appropriate investigations and follow-up of results
  • Assessment of lifestyle and preventive health issues
  • Arrangements are made for the physician's patients to be cared for in his/her absence
  • Emergency problems are dealt with promptly and effectively

2. Medical Records

  • Adequate notes for reader to follow present management
  • Stress quality of legibility
  • Patient identity is clearly evident on each chart component
  • Describe organization within charts, retrieval of items
  • Use of standard forms (cumulative patient profile, flow sheets, medications, history summary, etc.)
  • S.O.A.P. type or narrative notes covering all areas
  • Diagnosis and treatment plan are clearly stated
  • Allergies and drug reactions clearly documented, as well as dates of immunizations
  • Documentation of medications - type, duration, evidence of regular review
  • Significant positive and negative findings are recorded
  • System for acknowledgement and follow-up of abnormal test results
  • Retention of pathology reports, hospital discharge summaries, operative notes, etc.
  • Use of pediatric growth charts and Saskatchewan Prenatal Forms
  • Documented evidence that periodic general assessments are performed
  • Documented evidence that lifestyle and health maintenance issues are discussed
  • Identification of physicians making chart entries
  • Evidence of progress notes for management of chronic conditions
  • Recording in charts of significant telephone advice given

3. Physical Facilities and Practice Organization

a. General Office Facilities

  • Adequacy of total area - describe size, design, atmosphere, cleanliness, maintenance
  • Accessibility - wheelchair, parking, etc.
  • Waiting rooms - comfort, current reference and reading materials, toys
  • Examining rooms - adequate size and equipment, private
  • Washrooms - accessibility, cleanliness

b. Telephone System

  • Number of incoming lines and available staff for answering
  • Are fax, e-mail services available
  • Scheduled call back time or other means of returning calls
  • System to ensure incoming messages are appropriate directed and acknowledged
  • Physician's contactability during office hours as well as after hours on-call system

c. Appointment System

  • Does it satisfactorily accommodate patients
  • Booking rate (patients per hour) for new or full assessments
  • Booking rate (patients per hour) for repeat patients
  • Waiting time for appointments, waiting time in waiting room
  • Does physician keep to appointment schedule
  • System for urgent or emergency appointments
  • Is a Day Sheet maintained - manual or computerized
  • Mechanism to ensure patients are not missed in the waiting room

d. Filing System

  • Chart types - family or individual
  • Electronic Medical Records

e. Medical Instruments and Equipment

  • Ensure equipment, including minor surgical materials, is appropriate to the type of practice
  • Appropriate sterilization procedures in place
  • System for managing biomedical waste and medication disposal

f. Drug Supplies and Samples

  • Ensuring appropriate drugs are available and appropriately stored
  • Maintaining current list of drugs on hand, monitoring expiration dates
  • Narcotic/controlled drug security

g. Emergency Facilities

  • Emergency tray/cart - appropriately stocked, centrally stored, readily available
  • Availability of Adrenalin and appropriate syringes for administration
  • Presence of 9-1-1 service in community or alternate emergency personnel
  • List of minimal drugs and supplies in the clinic, monitoring of expiration dates
  • Knowledge of office staff in the event of an emergency of disaster

h. Laboratory Investigations

  • Type of investigations available
  • Are they accessible on-site or close by

i. Personnel

  • Number of staff persons, duties and training
  • Documented plans in place for handling emergencies in the office
  • Regular staff meetings/communications
  • Documented job descriptions and office policies

j. Walk-in Clinics

  • Determine whether physician provides ongoing or episodic care
  • Evidence of patient education regarding importance of regular visits to their family physician
  • Determine patients' family physician and document information in charts
  • Mechanism for provision of information to patients' family physician
  • System for handling non-urgent referrals
  • Provision for after hours coverage
  • Establishment of clinic policies and standards for employed physicians

k. Miscellaneous Observations

  • System for handling telephone requests for repeat prescriptions from patient or pharmacy
  • System for handling incoming reports, test results
  • System for handling consultations and referrals
  • Policy in place when a patient is dressing/undressing, is appropriate draping provided
  • Accessibility of reference materials for physicians and patients - hardcopy, electronic

L. Health Information Protectoin Act Compliance (HIPA)

  • Posters/brochures posted in clinics re privacy / patient confidentiality
  • Appointment of a privacy officer to deal with issues relating to patient confidentiality and HIPA
  • Security of patient records clinic
  • Staff and signed confidentiality agreements
You are here: Home Assessment Assessment Criteria